Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?

Yes

No

Category VIII

Greasy or high-fat foods cause distress

0

1

2

3

Lower bowel gas and/or bloating several hours after eating

0

1

2

3

Bitter metallic taste in mouth, especially in the morning

0

1

2

3

Burpy, fishy taste after consuming fish oils

0

1

2

3

Unexplained itchy skin

0

1

2

3

Yellowish cast to eyes

0

1

2

3

Stool color alternates from clay colored to normal brown

0

1

2

3

Reddened skin, especially palms

0

1

2

3

Dry or flaky skin and/or hair

0

1

2

3

History of gallbladder attacks or stones

0

1

2

3

Have you had your gallbladder removed?

Yes

No

Category IX

Acne and unhealthy skin

0

1

2

3

Excessive hair loss

0

1

2

3

Overall sense of bloating

0

1

2

3

Bodily swelling for no reason

0

1

2

3

Hormone imbalances

0

1

2

3

Weight gain

0

1

2

3

Poor bowel function

0

1

2

3

Excessively foul-smelling sweat

0

1

2

3

Category X

Crave sweets during the day

0

1

2

3

Irritable if meals are missed

0

1

2

3

Depend on coffee to keep going/get started

0

1

2

3

Get light-headed if meals are missed

0

1

2

3

Eating relieves fatigue

0

1

2

3

Feel shaky, jittery, or have tremors

0

1

2

3

Agitated, easily upset, nervous

0

1

2

3

Poor memory, forgetful between meals

0

1

2

3

Blurred vision

0

1

2

3

Category XI

Fatigue after meals

0

1

2

3

Crave sweets during the day

0

1

2

3

Eating sweets does not relieve cravings for sugar

0

1

2

3

Must have sweets after meals

0

1

2

3

Waist girth is equal or larger than hip girth

0

1

2

3

Frequent urination

0

1

2

3

Increased thirst and appetite

0

1

2

3

Difficulty losing weight

0

1

2

3

Category XII

Cannot stay asleep

0

1

2

3

Crave salt

0

1

2

3

Slow starter in the morning

0

1

2

3

Afternoon fatigue

0

1

2

3

Dizziness when standing up quickly

0

1

2

3

Afternoon headaches

0

1

2

3

Headaches with exertion or stress

0

1

2

3

Weak nails

0

1

2

3

Category XIII

Cannot fall asleep

0

1

2

3

Perspire easily

0

1

2

3

Under a high amount of stress

0

1

2

3

Weight gain when under stress

0

1

2

3

Wake up tired even after 6 or more hours of sleep

0

1

2

3

Excessive perspiration or perspiration with little or no activity

0

1

2

3

Category XIV

Edema and swelling in ankles and wrists

0

1

2

3

Muscle cramping

0

1

2

3

Poor muscle endurance

0

1

2

3

Frequent urination

0

1

2

3

Frequent thirst

0

1

2

3

Crave salt

0

1

2

3

Abnormal sweating from minimal activity

0

1

2

3

Alteration in bowel regularity

0

1

2

3

Inability to hold breath for long periods

0

1

2

3

Shallow, rapid breathing

0

1

2

3

Category XV

Tired/sluggish

0

1

2

3

Feel cold―hands, feet, all over

0

1

2

3

Require excessive amounts of sleep to function properly

0

1

2

3

Increase in weight even with low-calorie diet

0

1

2

3

Gain weight easily

0

1

2

3

Difficult, infrequent bowel movements

0

1

2

3

Depression/lack of motivation

0

1

2

3

Morning headaches that wear off as the day progresses

0

1

2

3

Outer third of eyebrow thins

0

1

2

3

Thinning of hair on scalp, face, or genitals, or excessive hair loss

0

1

2

3

Dryness of skin and/or scalp

0

1

2

3

Mental sluggishness

0

1

2

3

Category XVI

Heart palpitations

0

1

2

3

Inward trembling

0

1

2

3

Increased pulse even at rest

0

1

2

3

Nervous and emotional

0

1

2

3

Insomnia

0

1

2

3

Category XVI (Cont.)

Night sweats

0

1

2

3

Difficulty gaining weight

0

1

2

3

Category XVII (Males Only)

Urination difficulty or dribbling

0

1

2

3

Frequent urination

0

1

2

3

Pain inside of legs or heels

0

1

2

3

Feeling of incomplete bowel emptying

0

1

2

3

Leg twitching at night

0

1

2

3

Category XVIII (Males Only)

Decreased libido

0

1

2

3

Decreased number of spontaneous morning erections

0

1

2

3

Decreased fullness of erections

0

1

2

3

Difficulty maintaining morning erections

0

1

2

3

Spells of mental fatigue

0

1

2

3

Inability to concentrate

0

1

2

3

Episodes of depression

0

1

2

3

Muscle soreness

0

1

2

3

Decreased physical stamina

0

1

2

3

Unexplained weight gain

0

1

2

3

Increase in fat distribution around chest and hips

0

1

2

3

Sweating attacks

0

1

2

3

More emotional than in the past

0

1

2

3

Category XIX (Menstruating Females Only)

Perimenopausal

Yes

No

Alternating menstrual cycle lengths

Yes

No

Extended menstrual cycle (greater than 32 days)

Yes

No

Shortened menstrual cycle (less than 24 days)

Yes

No

Pain and cramping during periods

0

1

2

3

Scanty blood flow

0

1

2

3

Heavy blood flow

0

1

2

3

Breast pain and swelling during menses

0

1

2

3

Pelvic pain during menses

0

1

2

3

Irritable and depressed during menses

0

1

2

3

Acne

0

1

2

3

Facial hair growth

0

1

2

3

Hair loss/thinning

0

1

2

3

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?

Yes

No

Hot flashes

0

1

2

3

Mental fogginess

0

1

2

3

Disinterest in sex

0

1

2

3

Mood swings

0

1

2

3

Depression

0

1

2

3

Painful intercourse

0

1

2

3

Shrinking breasts

0

1

2

3

Facial hair growth

0

1

2

3

Acne

0

1

2

3

Increased vaginal pain, dryness, or itching

0

1

2

3

PART III

How many alcoholic beverages do you consume per week?

Rate your stress level on a scale of 1-10 during the average week:

How many caffeinated beverages do you consume per day?

How many times do you eat fish per week?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

File 1

File 2

File 3

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No matter the condition, we have the treatment for you. The expertise at Premier Medical Group ensure that you will never need to look elsewhere for your health needs. Our team includes medical doctors, nurse practitioners, doctors of chiropractic and acupuncturists. Our friendly and professional team will enable you to have a positive experience every time!